Pulm: ICU time

This week Dr. Ozzie and I were joined by an FP intern, Andrea, who was doing her ICU rotation and would be with us for a week. Dr. Ozzie had originally scheduled a lecture on hemodynamic shock next week, but he moved it to this afternoon so that Andrea could hear the lecture, too. It fell on me to contact the other four to let them know of this sudden change in plans. All of us were present at noon for the shock lecture, and much to my dismay when we were going over the basics of shock I started spouting off wrong answers. *sigh* Not the best way to impress the attending.

Dr. Ozzie got 3-4 new admits, including one in the ICU, so after giving a lecture on mechanical ventilation he emphasized that he expected Andrea and me to really know our stuff. I saw two of the patients: one really nice 85-year-old lady with a lower lobe pneumonia and an equally pleasant 66-year-old guy with a COPD exacerbation and MRSA. After that Dr. Ozzie met up with me and asked me what orders I wanted to write for the patients. Wow, he really is trying to get me prepped for residency! Not that I minded; I don't want to be a total idiot when I start residency. I also spent an afternoon at the PFT lab to see PFTs done (it was assigned to us; I'd already seen PFT testing back at Baylor). The first patient was a girl with CF who knew exactly what to do (she'd had tons of PFTs in the past); without anyone telling her, she took the apparatus and blew into it. And when the tech told her what her FEV1 and other values were, she looked happy. "See, that's better than last week!" she said to her mom. The second patient I saw was a really healthy 85-year-old lady who had some trouble with the apparatus at first but eventually figured it out. I'm amazed by how generally healthy the elderly population in East Texas is; yesterday in clinic I saw a couple in their 80s who went country line dancing on a weekly basis. I hope I'm in that good shape if I live be that old.

Pulm: Change of Pace

Dr. Ozzie was gone for the rest of the week so instead I was assigned to Amber's preceptor, Dr. JS (with whom I'd be working for the last two weeks of my rotation here). Dr. JS works long clinic hours, and today he also had to see Dr. Ozzie's inpatients. When he told Amber to see the inpatients, I offered to go with her since I knew them fairly well (having followed them for two days). The first patient we saw was a pleasant Vietnamese patient with miliary TB who had been presented at the TB conference yesterday for treatment options since she also had Hep C (and INH is hepatotoxic). This was the first time I ever met her since Dr. Ozzie had not let me see her previously, but she was very sweet. She told us that she had no idea when or how she contracted TB, and she was all alone since she had no children and her husband passed away within a year or two ago, but she was determined to get well no matter what, even if she had to stay in the hospital for one year. We assured her that most likely would not be the case, but she would definitely be on medications for six months to a year. Amber and I were both wearing the N95 duckbill masks, but as we examined her I couldn't help but wonder what my chances were of accidentally inhaling air droplets that contained TB and seroconverting into TB positive from this rotation. My other two patients were about the same, so I wrote notes for all 3 before we attended noon conference.

Kate has lobbied for us to get Good Friday off, and all we have to do now is fill out paperwork and clear things with our preceptors and lecturers. Lisa and I watched the series finale of ER tonight, and we were shocked when a placenta accreta/uterine inversion was shown in gory detail after a woman gave birth to twins. You didn't actually SEE the uterus or placenta, just tons of blood spilling down the foot of the bed to the floor, but the effect was pretty darn real. Having delivered several babies during my obgyn rotation, I was aware of how much a woman bled during birth, and this TV delivery gave a new meaning to "huge blood loss." Needless to say the woman went into DIC and died, but seeing all that (fake) blood on TV...damn.

Pulm: The Last Group

I've been assigned to inpatient medicine with Dr. "Ozzie," a pulmonology/critical care specialist, and he seemed happy when I told him I was specializing in medicine. He told me that sometimes he doesn't think pulmonology is a worthwhile rotation if the student in question is specializing in something like pathology, but since I'm going into medicine, there's lots he can teach me. And teach he did: he has me look at patients' CXRs and CT scans and pimped me on those. "What do you see?" he'd ask. One patient had a chronically elevated right hemidiaphragm secondary to scoliosis, but if I hadn't read the CT report I would have thought that hemidiaphragm was an infiltrate. I even got a sharp poke to the shoulder for saying (wrongly) that the left hemidiaphragm is usually higher. Clearly, since I'm a future medicine resident, he expects me to be at the top of my game. But that's fine.

This morning we had a TB conference at 8:30 a.m.. Dr. Ozzie had told me to finish rounding on my patients sometime between 9 and 10 a.m., and I was worried that I'd never get around to rounding on them. I gave him a call at 8:45 to let him know about the conference, and his reply: "Is there a conference today?" It turns out he was supposed to be at the conference to present one of his TB patients, so after my call he immediately hurried down to the conference room. Guess it was a good thing I decided to call him after all. I got to round on my patients after the conference; one of the COPDers went home and the other was in the hospital only because he had unexplained abdominal pain. His breathing was otherwise fine. My 19-year-old patient's lungs still sounded like crap, but at least he was out of the ICU.

At noon, while we were getting lunch, one of the residents said, "So, I heard you guys are the last ones to come here?" My classmates and I were confused, so he said that he heard that after this month, 4th year students will no longer be going to Tyler for rotations. "It's not because of dissatisfaction," he said, since students have been coming to Tyler for years, but because our school president was apparently getting rid of our off-site rotations or something weird like that. *sigh* I've given up trying to understand the things going on at our school. First the whole MD-DO "study group," and now AOA and TOMA have stopped funding the ORC, and now this. In a way I'm kind of relieved that I'm graduating this year; things at school are going downhill and I don't want to be around to see what happens.

Pulm: First Impressions

The drive to Tyler yesterday was fairly uneventful. Lisa and I are sharing a cabin while the others get cabins to themselves. On top of that, the UTHSC-Tyler is located on the outskirts of Tyler and literally in the middle of nowhere. It takes 15 minutes to actually drive into the town to get to the nearest grocery store or Chick-fil-A, as well as the UT-Tyler undergraduate campus. We're allowed to join the gym there for $25 so Lisa and I went there to get passes as an incentive to work out during our stay here.

Today was mostly orientation, as we learned MediTech (which was the same EMR used at Methodist so we've all seen it before) and toured the hospital. We also got a respiratory FIT test to make sure our "duckbill" masks were securely over our faces before we could see TB patients later on. They do this by making us wear a hood over our heads and then spraying saccharine into the hood, and if we taste the saccharine, we needed to start over. I tasted saccharine after one squirt. Kate and Amber lasted a bit longer, and Lisa made it all the way to the "walk in place" step before she tasted it. The tester lamented that this was the first time he had four people fail (Danny was late), but the second time around we all passed. After orientation, Jen came over to around dinnertime. Longview's not too far from Tyler so that made the visit possible.

Heme/Onc: Breast Day (Last Day!)

My last morning at the Center started out slow; I followed Sandy for about two patients before she "disappeared" (took her purse and went somewhere), so Dr. BR suggested that I follow Dr. RY, the breast cancer specialist of the group. I'd been wanting to work with her for sometime but never asked b/c she seemed so busy; Dr. RY is pretty famous in this part of town for her focus on breast cancer and women's health. As it turned out, she was also an excellent teacher and wanted me to learn everything I could about breast cancer in this one day I spent with her. For each breast cancer patient who came in, she asked me to do a breast exam right after she did (with the patient's permission, of course), and each patient was drastically different from the other. One woman had a unilateral mastectomy so I got to feel both the normal breast and the scarred tissue where the other breast used to be. Another woman had bilateral expanders s/p mastectomy on both sides, and those felt pretty firm (though I couldn't find the port where the saline is injected to make the expanders larger). Yet another woman had bilateral implants, and I was immediately stunned by how cool they felt to the touch. I recalled reading an article where a man wrote how he initially freaked out when he found out his girlfriend's breasts "weren't real," and now I understood what he meant. They just don't feel the same. We had one new patient, and Dr. RY spent an entire hour going over her medical history, diagnosis, and treatment options. Her explanations were such that an ordinary woman with no medical training could understand what was going on, so even if this was my first day of the heme-onc rotation and I knew nothing about breast cancer therapy, I could understand the way the drugs worked. The new patient had a rather small cancer that was removed by lumpectomy, but it was also grade II and lymphatic invasion, which is concerning for future recurrence. She was, however, very Type A and did not want chemo if it wasn't necessary (since the tumor had been removed with clean margins), opting for radiation only. Everyone has their own way of doing things. What impressed me the most about Dr. RY was her rapport with her patients. She sees only breast cancer patients (earlier today she and Dr. BR were trying to compare who had "crazier" patients), presumably all female (haven't seen a male breast cancer patient yet), and she builds relationships with them, woman to woman. There was one couple with whom she regularly joined in prayer at the end of the visit, and today she and Joi (her scribe) invited me to join them. The five of us then joined hands as Dr. RY thanked God for blessing our patient with good health, and I admired her for being able to pray with her patients on request. That's not something I myself would be comfortable with. Joi, after learning I played the violin, told me about a concert she attended in which the musician played a harp and described it as some of the most beautiful music she ever heard. I agreed; words can't describe what a harp sounds like when performed well. At the end of the day, I thanked Dr. BR, Dr. RY, and Helena for having me at the Center and they wished me all the best. I was sad to go; everyone at the Center had made me feel welcome, especially Drs. RP, MR, LM, and BR (with whom I probably spent the most time). As for my thoughts toward heme-onc, it really is a fascinating field and I can easily see myself going into heme/onc if not for the fact that I'm not a huge fan of research. We'll see what happens.

Heme/Onc: The Crazy Patient

The clinic was strangely empty today b/c there were only 3-4 physicians present at any given time; both NPs were out for the day. I worked with Dr. BR as usual, and when we saw how packed his schedule was, I offered to see some of his patients for him so then he'd only have to do a quickie on them. It worked well enough in the morning; I got to follow up on a lady I saw two weeks ago who went gambling in Oklahoma despite having a low white count (that wasn't about to stop her, and she earned $700) but there were still a few "crazy" patients that we had to see together. At one point Dr. MS (whom I've only seen twice before since I'm never at the Center on Thursdays) told Dr. BR there was someone she wanted him to meet, but that "someone" turned out to be one of the crazy patients. "Want to be my boyfriend?" she asked. I was around the corner so I didn't see the look on Dr. BR's face, but nearby the MAs were trying to hide their laughter. "I got a boyfriend," the patient continued. "He's a n*****." Now I was the one trying not to laugh as Dr. BR tried to tell her not to use that term (though it's apparently more acceptable if African Americans use that term on each other), and she asked if he was trying to get rid of her. By the time Dr. BR finally got away from that patient, he looked pretty beat up and Dr. MS was laughing. "When you said you wanted me to meet someone, I thought you meant someone young and good looking!" he said. Dr. MS just smiled and said, "I think she's going to transfer her care to you." Hopefully not.

One of the patients we saw was actually a man I saw in Weatherford with Dr. RP weeks ago; I remembered him b/c he and his wife live in Mansfield but were willing to travel a long way to Weatherford just to see Dr. RP. He was in horrible shape; his wife said he'd only had a few cups of jello in the span of one week and was so weak that he could barely lift his head (or himself off the floor when he fell). Fortunately all parties agreed that he needed to be hospitalized immediately and arrangements were made for him to go to Harris. Hopefully the waiting room will be empty so he'll get admitted immediately. I have to admit, I miss ER sometimes.

Dr. BR still had 2 patients to see at 12:15 but sent me upstairs to grab some food. Today's menu was Panera Bread, and as soon as the social worker saw me (she knew I was Dr. BR's student), she asked where Dr. BR was. I said he was still working, and she said that after yesterday's fiasco (we got up to the lounge at 12:45 to find almost no food left), she saved him a plate. I didn't think she needed to worry yet since there was still plenty of food to go around. Scott joked, "Tell Dr. BR he's such a girl, being so high maintenance." I later passed the message along, and Dr. BR retorted that obviously Scott doesn't know what it's like to go hungry since he's gained a lot of weight recently. LOL. That's one thing I love about the dynamic at the Center; everyone jokes around a lot yet gets along well. I don't know how many times Dr. BR has teased the NPs for "being old," since they have children his age, but Dr. LM gets a few insults in now and then as well.

Heme/Onc: Difficult patients

This morning I paired up with Dr. BR, but before we saw any patients I got to listen as Helena and Dr. RY discussed a "horrible" patient who turned up the drip on her Taxol (?) chemo so that she could finish a 3 hr treatment in just 15-30 minutes. "Did she not realize that she could have died from that?" said Dr. RY. Apparently this is not the first time this woman acted up though; there were stories being exchanged about her left and right for a while. We saw our pancreatic cancer lady again (fortunately she didn't bring any vases or flowers; the flowers she gave Dr. BR yesterday have all dried up but are still pretty), and then we got a patient that really made Dr. BR groan.

Mr. C was a 78-year-old former lawyer with head and neck cancer that has metastasized to his facial nerves and given him a right face droop, and one side of his vocal cords is paralyzed so that his speech is really soft and hoarse. Now he has trouble swallowing and will need a PEG tube for nourishment, which he is not too keen about. He and his wife were reportedly "angry" about the delay in treatment that led to his present symptoms when in fact he was the one who wavered between surgery and Cyberknife (he was afraid surgery guaranteed his facial nerve paralysis, and he "fired" the neurosurgeon b/c the neurosurgeon was pushing for surgery), and now he didn't want the PEG tube. He described having a PEG tube like being a "cadaver with blood flowing," which made no sense. Dr. BR patiently explained that many people have continued to lead fulfilling lives s/p PEG tube insertion and that it was not the end of the world. Even after the 20-30 minute discussion, however, the patient wasn't convinced, and his wife later contacted Dr. BJ, his previous oncologist (the former president of the Center who retired earlier this year) "just to talk" about their frustrations. *sigh* It was funny when Dr. BJ forgot which doctors worked which days; he said, "Guess that happens when you don't have a regular schedule." This was, of course, referring to the fact that he was retired, and the other doctors were quick to tell him to leave the workroom (for rubbing it in)

I got to follow Dr. LM in the afternoon and got pimped on CML and even the AML: M3. He asked me what the translocation of AML: M3 (aka APL) was, and thank goodness for Dr. Barone's lectures; I remembered the 15:17. Dr. LM looked impressed and said I was on a roll, and I later shared the story of the 15-17 year old teenager wandering in the "trans" district of some street looking for some DIC and hopping in a black sudan. The stain was "Sudan black" so Helena and Dr. LM didn't get that part at first, but they both got the DIC part down, hehe.

Heme/Onc: Tumor Board patient

This entire week I'm at the Center downtown, and I spent yesterday and today working with Dr. MR. He's one of the heme/oncs who seems to like having a student around b/c he can teach while we're in the patient's room. Sometimes, however, he talks as though the patient isn't there and uses a lot of medical terminology which has the patient feeling (and looking) left-out and confused. With him around, I'm introduced as Dr. ____, which feels anticlimatic b/c in less than 2 months I will be Dr. ____. It's a scary, yet exciting thought. Tumor Board was this morning, and as expected, Dr. MR had me present our patient from last week. I hit the important points and then asked the other oncologists whether they'd treat my lung cancer patient, who is not a surgical candidate, with radiation only or radiation plus chemo. His mets were in three isolated regions, so they COULD be hit by radiation only, but the chances of micrometastases was also high. Ultimately, the doctors thought that a combination of both chemo and radiation would give the patient the best shot at survival (aside from CAD, he's a pretty healthy 78-year-old). Afterwards Dr. MR said I did a good job in presenting our patient, and I was happy to hear it. Now if only Dr. RP could have seen me; that could have helped my grade. But he'll learn about it if he asks the other doctors for feedback.

We saw our patient and his (neurotic) wife later this afternoon, and when Dr. MR brought up the topic of chemotherapy, they looked surprised. "We met with Dr. L (the radiation oncologist) earlier this morning, and he didn't say anything about chemotherapy," said the wife. "We thought he only needed radiation." This led to about 5-10 minutes of confusion as Dr. MR tried to explain where we were coming from while the wife was indignant over hearing two different things from two doctors. "I don't think we should have chemo," the wife said, and Dr. MR, obviously wanting to avoid an argument, said that we could try radiation first and if that doesn't work, then consider the chemo. The wife seemed satisfied with this, and so did the patient. But when they left, Dr. MR shook his head. We had another patient come in whose wife was in late-stage dementia, and Dr. MR commented that he would rather be dead than in that state. Not the first time I've heard comments like that from doctors.

I told Dr. MR that I'd matched in Philadelphia. He didn't respond to the name "Drexel" but as soon as I said "Hahnemann University Hospital" he knew exactly which program I was talking about (HUH didn't merge with Drexel until a few years ago). "That's an excellent teaching hospital," he said. "You'll learn a lot there." The other doctors overheard us talking about Philadelphia so I told them I matched there, and they offered their congrats. Dr. BR offered to get in touch with some of his friends up there and ask them about places to live in Philly for me, which I thought was nice of him. "City of Brotherly Love," he said. Dr. MR added, "Just be sure you get off at the right stop at the subway," meaning that Philly can be dangerous. Yes, I know.

Heme/Onc: After the Match

This morning I brought the TCOM 2009 residency list that Dr. D sent out for Dr. RP to see. He seemed concerned by the low number of IM applicants (about 15), whereas we had about 8 psych and 16 ER, among others. I think our class has a lot of specialty representation this year, including one psych/neuro (Matt) and one FP/psych (unknown). Only Clark matched at JPS for family medicine, which was a big surprise since I know a lot of FP classmates had interviewed there and ranked it pretty high. Dr. RP then voiced his opinion that JPS was not DO friendly. I definitely got that impression from the surgeons, but not so much in FP and ob-gyn. I wouldn't know about psych since I didn't do my rotation there, but Jacob and Aaron matched so there should be less discrimination psych-wise. Dr. RP said that when he first came to work at Harris, the people up there tried everything in their power to get him kicked out b/c he was a DO, never mind that he was a former chief fellow at MD Anderson with excellent credentials. *sigh* I hope I don't have that problem in the future.

The last day at this clinic was fairly uneventful until our last patient was seen (SCLC patient with 3 sons with her; at least she has a good support system) and Dr. RP reminded me that I had to play my violin for the clinic in order to get an A (joking). So I played a few tunes from "Canon in D," "Spring" from Vivaldi's Four Seasons, and "West Side Story." Dr. RP also found some sheet music from "Schindler's List" that I was able to sightread, and he said there was something nice about hearing music live. I think so too =)

After work I stopped by the Poly Clinic to see Dr. RR, my family medicine preceptor who'd written one of my LORs. I hadn't seen him in almost a year, and he looked like he had more white hairs than before, but he recognized me almost immediately. I told him where I matched and he said I deserved to go where I wanted to go. I said, "I have to thank you as well. The school said your letter was the best of the bunch." (which was true). Dr. RR brushed it off, saying that I was a good student who worked hard. He said that when he started his internship at JPS, he was paged almost as soon as he walked into the door b/c his team was on call that night. Wow. I hope my first day of work isn't like that =P

Match Day

We were given the opportunity to call the school at 10:40 a.m. today to find out where we matched, but I was determined to do things the old fashioned way and wait until noon to check my match status online. I wanted to see the name of my future residency program with my own eyes; just hearing it over the phone wouldn't be enough to convince me of anything. The morning was pretty slow (at one point we had a 1 hr break between patients) so Dr. RP, Shandy, Martha, and I chatted about places to visit in Colorado (Shandy's going on vacation there in June with her family), music (Dr. RP's mother-in-law teaches piano), and American Idol. I mentioned that I couldn't watch American Idol b/c it makes my ears bleed (the problem with having perfect pitch), and Shandy asked if I played any instrument. I said I played the violin, and she said I should bring it tomorrow and play for everyone. "It'll get you an A if you do," joked Dr. RP, so I agreed. Even if my grade wasn't at stake I would have done it =P

At 11:55 a.m. I checked my email and got the following:

Drexel Univ COM/Hahnemann Univ Hosp-PA

I was not surprised to learn that I'd matched at Drexel; I had my best interviews there and had a pretty good feeling that I'd probably end up at Philadelphia. With that, I told Dr. RP and the others where I got accepted and then called my mom and sister to tell them the news. At first my mom didn't know where Drexel was, but when I said Philadelphia, she said, "Oh! Your dad likes that program, too!" I was relieved that my parents were happy with where I ended up; they've been to Philadelphia before and think it's a nice city to live in.

Dr. RP let me take the rest of the afternoon off so I could meet "the gang" for lunch at Cousin's. Everyone was smiling and happy that this whole waiting game was over. Then of course we went to Blue Mesa to find out where everyone else was going. It was the first time most of our class has been together in over a year, and it didn't matter whether we knew each other well or not, everyone was conversational and asking where each other ended up. Even Dr. D stopped by briefly to offer his congratulations. It was a nice way to celebrate our achievement, and everyone there was smiling and happy. That's all that matters =)